Outcomes of regenerative treatment for over 200 patients with tympanic membrane perforation

OBJECTIVE

To evaluate outcomes of a regenerative treatment (RT) for over 200 patients with tympanic membrane perforation (TMP). The RT-TMP method involves a gelatin sponge, basic fibroblast growth factor (bFGF) and fibrin glue.

METHODS

The study population included 216 patients and 234 ears (male: female =100:116; age 1-93 years). All enrolled patients were treated with RT-TMP in which TMP edges were disrupted mechanically and a gelatin sponge immersed in bFGF was inserted into the perforation. Fibrin glue was then dripped over the sponge. Patient outcomes including TMP closure rates, change in hearing level, and complications were obtained from retrospective medical chart reviews. The TMP was examined three or more weeks after surgery. The treatment was repeated up to 4 times until complete TMP closure was achieved.

RESULTS

After mechanical disruption, the perforation size was Grade I, ≤1/3 of entire TM area in 22 ears (9.4 %), Grade II, 1/3-2/3 of entire TM in 77 ears (32.9 %) and Grade III, ≥2/3 of entire TM area in 135 ears (57.7 %). The overall TMP closure rates were 97.0 % (227/234). Complete TMP closure was achieved in 68.8 % (161/234), 22.6 % (53/234), 4.7 % (11/234) and 0.9 % (2/234) of ears after 1, 2, 3 and 4 treatments, respectively. In 7 of 234 ears (3.0 %), the TMPs were not closed completely after 4 treatments. There was no correlation between TMP size after mechanical disruption and number of treatments required to achieve complete closure (Fisher's exact test p = 0.70). The mean air-conduction hearing threshold at low frequency improved from 57.3 ± 16.7 dB before treatment to 37.3 ± 16.0 dB (p < 0.0001) after closure of TMPs. For middle and high frequencies, the improvement was 49.0 ± 19.3 dB to 36.9 ± 17.9 dB (p < 0.0001) and 57.7 ± 22.9 dB to 49.2 ± 23.3 dB (p < 0.0001), respectively. The mean air-bone gaps also improved significantly, and were within 10 dB at 250 Hz, 500 Hz and 1 kHz, and 11 dB at 2 kHz. One or more complications occurred in 32 patients (32/216; 14.8 %). The most common complication was formation of an epithelial pearl (16 ears; 6.8 %), followed by severe TM retraction (9 ears; 3.8 %) and otitis media with effusion (6 ears; 2.6 %). There were no serious complications that caused deterioration of the patient's general condition.

CONCLUSION

Our results showed that RT-TMP had high success rates for TMP closure and good hearing improvement and produced no severe complications that could affect general health status. This novel therapy is simple, safe and minimally invasive, and could help improve the quality of life in patients with TMP.

Giant X-Ray Circular Dichroism in a Time-Reversal Invariant Antiferromagnet

X-ray circular dichroism, arising from the contrast in X-ray absorption between opposite photon helicities, serves as a spectroscopic tool to measure the magnetization of ferromagnetic materials and identify the handedness of chiral crystals. Antiferromagnets with crystallographic chirality typically lack X-ray magnetic circular dichroism because of time-reversal symmetry, yet exhibit weak X-ray natural circular dichroism. Here, the observation of giant natural circular dichroism in the Ni L3-edge X-ray absorption of Ni3TeO6 is reported, a polar and chiral antiferromagnet with effective time-reversal symmetry. To unravel this intriguing phenomenon, a phenomenological model is proposed that classifies the movement of photons in a chiral crystal within the same symmetry class as that of a magnetic field. The coupling of X-ray polarization with the induced magnetization yields giant X-ray natural circular dichroism, revealing typical ferromagnetic behaviors allowed by the symmetry in an antiferromagnet, i.e., the altermagnetism of Ni3TeO6. The findings provide evidence for the interplay between magnetism and crystal chirality in natural optical activity. Additionally, the first example of a new class of magnetic materials exhibiting circular dichroism is established with time-reversal symmetry.

Divergent neurodevelopmental profiles of very-low-birth-weight infants

BACKGROUND

Advanced perinatal medicine has decreased the mortality rate of preterm infants. Long-term neurodevelopmental outcomes of very-low-birth-weight infants (VLBWIs) remain to be investigated.

METHODS

Participants were 124 VLBWIs who had in-hospital birth from 2007 to 2015. Perinatal information, developmental or intelligence quotient (DQ/IQ), and neurological comorbidities at ages 3 and 6 years were analyzed.

RESULTS

Fifty-eight (47%) VLBWIs received neurodevelopmental assessments at ages 3 and 6 years. Among them, 15 (26%) showed DQ/IQ <75 at age 6 years. From age 3 to 6 years, 21 (36%) patients showed a decrease (≤-10), while 5 (9%) showed an increase (≥+10) in DQ/IQ scores. Eight (17%) with autism spectrum disorder or attention-deficit hyperactivity disorder (ASD/ADHD) showed split courses of DQ/IQ, including two with ≤-10 and one with +31 to their scores. On the other hand, all 7 VLBWIs with cerebral palsy showed DQ ≤35 at these ages. Magnetic resonance imaging detected severe brain lesions in 7 (47%) of those with DQ <75 and 1 (18%) with ASD/ADHD.

CONCLUSIONS

VLBWIs show a broad spectrum of neurodevelopmental outcomes after 6 years. These divergent profiles also indicate that different risks contribute to the development of ASD/ADHD from those of cerebral palsy and epilepsy in VLBWIs.

IMPACT

Very-low-birth-weight infants (VLBWIs) show divergent neurodevelopmental outcomes from age 3 to 6 years. A deep longitudinal study depicts the dynamic change in neurodevelopmental profiles of VLBWIs from age 3 to 6 years. Perinatal brain injury is associated with developmental delay, cerebral palsy and epilepsy, but not with ASD or ADHD at age 6 years.

Construction of brain area risk map for decision making using surgical navigation and motor evoked potential monitoring information

PURPOSE

Surgical devices or systems typically operate in a stand-alone manner, making it difficult to perform integration analysis of both intraoperative anatomical and functional information. To address this issue, the intraoperative information integration system OPeLiNK^® was developed. The objective of this study is to generate information for decision making using surgical navigation and intraoperative monitoring information accumulated in the OPeLiNK^® database and to analyze its utility.

METHODS

We accumulated intraoperative information from 27 brain tumor patients who underwent resection surgery. First, the risk rank for postoperative paralysis was set according to the attenuation rate and amplitude width of the motor evoked potential (MEP). Then, the MEP and navigation log data were combined and plotted on an intraoperative magnetic resonance image of the individual brain. Finally, statistical parametric mapping (SPM) transformation was performed to generate a standard brain risk map of postoperative paralysis. Additionally, we determined the anatomical high-risk areas using atlases and analyzed the relationship with each set risk rank.

RESULTS

The average distance between the navigation log corresponding to each MEP risk rank and the anatomical high-risk area differed significantly between the with postoperatively paralyzed and without postoperatively paralyzed groups, except for "safe." Furthermore, no excessive deformation was observed resulting from SPM conversion to create the standard brain risk map. There were cases in which no postoperative paralysis occurred even when MEP decreased intraoperatively, and vice versa.

CONCLUSION

The time synchronization reliability of the study data is very high. Therefore, our created risk map can be reported as being functional at indicating the risk areas. Our results suggest that the statistical risks of postoperative complications can be presented for each area where brain surgery is to be performed. In the future, it will be possible to provide surgical navigation with intraoperative support that reflects the risk maps created.

Radiomics model of diffusion-weighted whole-body imaging with background signal suppression (DWIBS) for predicting axillary lymph node status in breast cancer

BACKGROUND

In breast cancer diagnosis and treatment, non-invasive prediction of axillary lymph node (ALN) metastasis can help avoid complications related to sentinel lymph node biopsy.

OBJECTIVE

This study aims to develop and evaluate machine learning models using radiomics features extracted from diffusion-weighted whole-body imaging with background signal suppression (DWIBS) examination for predicting the ALN status.

METHODS

A total of 100 patients with histologically proven, invasive, clinically N0 breast cancer who underwent DWIBS examination consisting of short tau inversion recovery (STIR) and DWIBS sequences before surgery were enrolled. Radiomic features were calculated using segmented primary lesions in DWIBS and STIR sequences and were divided into training (n = 75) and test (n = 25) datasets based on the examination date. Using the training dataset, optimal feature selection was performed using the least absolute shrinkage and selection operator algorithm, and the logistic regression model and support vector machine (SVM) classifier model were constructed with DWIBS, STIR, or a combination of DWIBS and STIR sequences to predict ALN status. Receiver operating characteristic curves were used to assess the prediction performance of radiomics models.

RESULTS

For the test dataset, the logistic regression model using DWIBS, STIR, and a combination of both sequences yielded an area under the curve (AUC) of 0.765 (95% confidence interval: 0.548-0.982), 0.801 (0.597-1.000), and 0.779 (0.567-0.992), respectively, whereas the SVM classifier model using DWIBS, STIR, and a combination of both sequences yielded an AUC of 0.765 (0.548-0.982), 0.757 (0.538-0.977), and 0.779 (0.567-0.992), respectively.

CONCLUSIONS

Use of machine learning models incorporating with the quantitative radiomic features derived from the DWIBS and STIR sequences can potentially predict ALN status.

Analyzing the Local Electronic Structure of Co3O4 Using 2p3d Resonant Inelastic X-ray Scattering

We present the cobalt 2p3d resonant inelastic X-ray scattering (RIXS) spectra of Co₃O₄. Guided by multiplet simulation, the excited states at 0.5 and 1.3 eV can be identified as the ⁴ T ₂ excited state of the tetrahedral Co²⁺ and the ³ T _2g excited state of the octahedral Co³⁺, respectively. The ground states of Co²⁺ and Co³⁺ sites are determined to be high-spin ⁴ A ₂(T _d ) and low-spin ¹ A _1g (O_h ), respectively. It indicates that the high-spin Co²⁺ is the magnetically active site in Co₃O₄. Additionally, the ligand-to-metal charge transfer analysis shows strong orbital hybridization between the cobalt and oxygen ions at the Co³⁺ site, while the hybridization is weak at the Co²⁺ site.

Combined effect of pulmonary rehabilitation and music therapy in patients with chronic obstructive pulmonary disease

[Purpose] We aimed to analyze parameters of pulmonary function and physiological, psychological, and physical factors in patients with chronic obstructive pulmonary disease (COPD) receiving pulmonary rehabilitation (PR) and music therapy (MT). [Participants and Methods] This randomized crossover comparative study included in-patients diagnosed with COPD and a ratio of forced expiratory volume measured at the first second and forced vital capacity (FEV1/FVC) of <70% after administration of a bronchodilator. Patients were randomly divided into two groups that received either PR only or MT and PR (n=13 each). The PR program included conditioning, respiratory muscle training, and endurance training, whereas the MT program included vocal, singing, and breathing exercises using a keyboard harmonica. The programs lasted 8 weeks, in which pre- and post-intervention data were compared every 4 weeks. [Results] The FEV1/FVC in the MT group improved after the intervention. Expiratory volume control was obtained better with feedback by sound than with expiration practice. In the MT and PR program, it was easier to adjust the timing and volume of breathing, obtain expiratory volume control, and, thus, improve FEV1/FVC than in conventional practice. [Conclusion] Combining MT with PR improves parameters of pulmonary function in patients with COPD. Music therapy is a novel approach that, in combination with PR, may be used in COPD management.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Video-based neonatal state assessment method for timing of procedures

BACKGROUND

Procedures should be performed when an infant is most receptive to disruptions in order to reduce the stress on the infant. However, frequent direct observations place a heavy burden on medical staff. There is therefore a need for a method for quantitatively and automatically evaluating the neonatal state.

METHODS

Ten infants in our hospital were enrolled in this study. The states of the infants were assessed by medical staff using the Brazelton Neonatal Behavioral Assessment Scale and were recorded on video at the same time. The recorded states were reclassified as activity levels, a new state classification method that includes middle activity, which is the appropriate time for a procedure. Using image analysis, motions of the infant were quantified as two indices: activity and pause time. Activity and pause time were compared for each activity level. The cutoff values of the indices were calculated, and the sensitivity and specificity of the middle activity were calculated.

RESULTS

There was a significant difference between all groups of activity level (P < 0.01). The maximum sensitivity and specificity of middle activity were 71.7% and 51.2%, respectively.

CONCLUSIONS

The neonatal state of infants can be quantitatively and automatically evaluated using video cameras, and the activity level can be used to determine an appropriate time for procedures in infants. This will reduce the burden on medical staff and lead to less stressful procedures for infants.

Two new records of powdery mildews (Erysiphaceae) from Japan: Erysiphe actinidiicola sp. nov. and Erysiphe sp. on Limonium tetragonum

Erysiphe actinidiicola on Actinidia polygama is described based on morphological and molecular data. Erysiphe actinidiicola is distinguished from E. actinidiae var. actinidiae by having irregularly to dichotomously branched chasmothecial appendages, larger chasmothecia sizes and numbers of asci per chasmothecium. Molecular analyses indicated that this species forms a clade separated from E. actinidiae var. actinidiae. An epitype is proposed for E. actinidiae var. actinidiae with ex-epitype sequences. A powdery mildew found on Limonium tetragonum is tentatively described as Erysiphe sp. This species is distinguished from E. limonii, a powdery mildew on Limonium spp., based on the DNA sequence differences in the 28S rDNA and internal transcribed spacer region as well as the morphological differences in the length of the conidiophores. This is the first record of powdery mildew on L. tetragonum in the world.

Development of the Soft X-ray AGM-AGS RIXS beamline at the Taiwan Photon Source

We report on the development of a high-resolution and highly efficient beamline for soft X-ray resonant inelastic X-ray scattering (RIXS) located at the Taiwan Photon Source. This beamline adopts an optical design that uses an active grating monochromator (AGM) and an active grating spectrometer (AGS) to implement the energy compensation principle of grating dispersion. Active gratings are utilized to diminish defocus, coma and higher-order aberrations, as well as to decrease the slope errors caused by thermal deformation and optical polishing. The AGS is mounted on a rotatable granite platform to enable momentum-resolved RIXS measurements with scattering angles over a wide range. Several high-precision instruments developed in-house for this beamline are described briefly. The best energy resolution obtained from this AGM-AGS beamline was 12.4 meV at 530 eV, achieving a resolving power of 4.2 × 104, while the bandwidth of the incident soft X-rays was kept at 0.5 eV. To demonstrate the scientific impact of high-resolution RIXS, we present an example of momentum-resolved RIXS measurements on a high-temperature superconducting cuprate, i.e. La2-xSrxCuO4. The measurements reveal the A1g buckling phonons in superconducting cuprates, opening a new opportunity to investigate the coupling between these phonons and charge-density waves.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Saturation and self-absorption effects in the angle-dependent 2p3d resonant inelastic X-ray scattering spectra of Co3

Angle-dependent 2p3d resonant inelastic X-ray scattering spectra of a LaCoO3 single crystal and a 55 nm LaCoO3 film on a SrTiO3 substrate are presented. Theoretical calculation shows that, with ∼20 meV resolved Co 2p3d resonant inelastic X-ray scattering (RIXS), the excited states of the isotropic 1A1g(Oh) ground state are split by 3d spin-orbit coupling, which can be distinguished via their angular dependence. However, strong self-absorption and saturation effects distort the spectra of the LaCoO3 single crystal and limit the observation of small angular dependence. In contrast, the RIXS on 55 nm LaCoO3 shows less self-absorption effects and preserves the angular dependence of the excited states.

The iArmS Robotic Armrest Prolongs Endoscope Lens–Wiping Intervals in Endoscopic Sinus Surgery

Objective. Fouling of the endoscope lens is a major problem in endoscopic sinus surgery (ESS). We examined whether the use of the intelligent arm support system (iArmS), a robotic armrest, could prolong endoscope lens–wiping intervals in ESS and thus allow for continuously clear endoscopic images. Study Design. This study is a prospective, nonrandomized crossover study. Methods. Three surgeons who performed ESS at 2 centers each conducted 3 operations with the iArmS and 3 operations without the iArmS; thus, 18 operations were assessed. To blind the assessments, we performed them prospectively without informing subjects of the endpoints. We recorded the operations and observed the recordings at a later date; endoscope lens–wiping times were noted in seconds to determine the endoscope lens–wiping intervals. Our examination was based on the null hypothesis that endoscope lens–wiping intervals would not differ according to the use or nonuse of the iArmS. Results. The median endoscope lens–wiping intervals with and without using the iArmS were 361 seconds and 135 seconds, respectively. Based on the Wilcoxon rank-sum test, this difference was significant ( P = 0.001); thus, the null hypothesis was rejected. This result indicated that endoscope lens–wiping intervals are greatly prolonged by the use of the iArmS. Conclusion. The iArmS robotic armrest is suitable for ESS, prolongs endoscope lens–wiping intervals, and facilitates obtaining continuous clear endoscopic images.

STMO-06 SMART CYBER OPERATING THEATER REALIZED BY INTERNET OF THINGS - RESULTS OF CLINICAL STUDY FOR 56 CASES

PURPOSE

Unlike conventional operating rooms that provide a sterilized space, we have developed a Smart Cyber Operating Theater (SCOT) in which the room itself performs treatment as a single medical device. We report the clinical results of 3 types of SCOT.

METHODS

Basic SCOT packaged with intraoperative MRI (0.4Tesla) was introduced in Hiroshima University in 2016. Standard SCOT networked with middleware OPeLiNK was introduced to Shinshu University in 2018, and Hyper SCOT introduced to Tokyo Women’s Medical University in 2019.

RESULTS

The average of all 56 patients was 44 years old. There were 38 brain tumors (68%), 11 functional diseases (19%), and 7 orthopedic diseases (13%). Basic SCOT is used for 41 cases (/56; 73%) with 22 gliomas, 10 epilepsies, 7 bone tumors, and 2 benign brain tumors. Standard SCOT with 20 networked devices is used for 14 cases (/56; 25%) with 6 gliomas including brain stem and thalamus, 6 pituitary tumors and 2 benign brain tumors. The strategy desk can display a variety of digital data synchronized in time, and the review and comment functions also operate. It is useful for remote advice through mutual communication via strategy desk. Hyper SCOT was used in February 2019 for the first case (1/56 cases; 2%). MRI images were taken with an average of 1.3 shots with good image quality. For 46/56 neoplastic lesions (82%), additional removal of residual tumor was performed in 31/46 cases (67%), and 26/46 cases (57%) were totally removed, with an average removal rate of 89.2%. There was no reoperation (0%) within 1 month in all cases.

CONCLUSIONS

Three types of SCOT contributed to planned surgical outcome including maximal tumor resection without serious related complications. We will proceed with verification of clinical effects, and develop robotized devices, and utilize AI for strategy desk at Hyper SCOT.

GATOR: connecting integrated operating room solutions based on the IEEE 11073 SDC and ORiN standards

PURPOSE

Medical device interoperability in operating rooms (OR) provides advantages for both, patients and physicians. Several approaches were made to provide standards for successful device integration. However, with high heterogeneity of standards in the market, device vendors may reject these approaches. The aim of this work is therefore to provide a proof of concept for the connection of two promising integration solutions OR.NET and SCOT to increase vendor interest.

METHODS

The connection of devices between both domains is targeted by implementing an application to map device capabilities between the IEEE 11073 SDC and ORiN standards. Potential properties of the respective architectures are defined. The connection was evaluated by latency measurements in a demonstrator setup utilizing an OR light as an exemplary device.

RESULTS

The latency measurements resulted in a similar transmission speed of the GATOR (53.0 ms) and direct SDC-to-SDC (38.0 ms) communication. Direct proprietary ORiN-to-ORiN communication was faster in any case (8.0 ms).

CONCLUSION

A connection between both standards was successfully achieved via the GATOR application. The results show comparable magnitudes of the communication between the standards compared to the direct standard-internal communication.

Sonodynamic Therapy With Anticancer Micelles and High-Intensity Focused Ultrasound in Treatment of Canine Cancer

Sonodynamic therapy (SDT) is a minimally invasive anticancer therapy involving a chemical sonosensitizer and high-intensity focused ultrasound (HIFU). SDT enables the reduction of drug dose and HIFU irradiation power compared to those of conventional monotherapies. In our previous study, mouse models of colon and pancreatic cancer were used to confirm the effectiveness of SDT vs. drug-only or HIFU-only therapy. To validate its usefulness, we performed a clinical trial of SDT using an anticancer micelle (NC-6300) and our HIFU system in four pet dogs with spontaneous tumors, including chondrosarcoma, osteosarcoma, hepatocellular cancer, and prostate cancer. The fact that no adverse events were observed, suggests the usefulness of SDT.

Function of Epirubicin-Conjugated Polymeric Micelles in Sonodynamic Therapy

The combinatory use of high-intensity focused ultrasound (HIFU) and epirubicin (EPI)-conjugated polymeric micellar nanoparticles (NC-6300) is thought to be a less invasive and more efficient method of cancer therapy. To investigate the mechanism underlying the combination effect, we examined the effect of trigger-pulsed HIFU (TP-HIFU) and NC-6300 from the perspective of reactive oxygen species (ROS) generation, which is considered the primary function of sonodynamic therapy (SDT), and changes in drug characteristics. TP-HIFU is an effective sequence for generating hydroxyl radicals to kill cancer cells. EPI was susceptible to degradation by TP-HIFU through the production of hydroxyl radicals. In contrast, EPI degradation of NC-6300 was suppressed by the hydrophilic shell of the micelles. NC-6300 also exhibited a sonosensitizer function, which promoted the generation of superoxide anions by TP-HIFU irradiation. The amount of ROS produced by TP-HIFU reached a level that caused structural changes to the cellular membrane. In conclusion, drug-conjugated micellar nanoparticles are more desirable for SDT because of accelerated ROS production and drug protection from ROS. Furthermore, a combination of NC-6300 and TP-HIFU is useful for minimally invasive cancer therapy with cooperative effects of HIFU-derived features, antitumor activity of EPI, and increased ROS generation to cause damage to cancer cells.

Usefulness of a Newly Developed Ultrasonic Microdissector in Neurosurgery: A Preliminary Experimental Study

BACKGROUND

Dissection and division of tissues are widely performed in microscopic neurosurgery, especially in brain tumor resection. Dissection maneuvers can be divided into two types: sharp dissection with microscissors and blunt dissection using a dissector. It is essential to use the appropriate method according to the intraoperative situation and conditions. Therefore, specific tools for each type of dissection maneuver are required. We developed an ultrasonic microdissector, a newly designed tool that functions as both microscissors and dissector to further advance brain tumor surgery. This preliminary experimental study was performed to evaluate the usefulness of this new device.

METHODS

Solfy F (J. Morita Mfg. Corp., Kyoto, Japan), a dental ultrasonic instrument, was used to provide power in this study. Two experiments were performed. The first one involved touching the brain parenchyma of a pig cadaver with the tip of the ultrasonic microdissector under various conditions to investigate its side effects. In the second experiment, the rat femoral artery, vein, and nerve were dissected from surrounding structures using a prototype of the ultrasonic microdissector. The effects of this device were then investigated histologically.

RESULTS

The amount of tissue damage was greater with the higher ultrasonic power. No irrigation and a long manipulation time also affected tissue degeneration. Dissection using the ultrasonic microdissector was superior to conventional dissection methods in terms of time (p < 0.05) and safety without any additional histologic damages.

CONCLUSIONS

The newly developed ultrasonic microdissector can dissect soft tissue without damage to the surrounding tissue. Further studies are required to determine the optimal intensity for its clinical use.

Profile of the ORION (Osaka emergency information Research Intelligent Operation Network system) between 2015 and 2016 in Osaka, Japan: a population-based registry of emergency patients with both ambulance and in-hospital records

Aim

To describe the registry design of the Osaka Emergency Information Research Intelligent Operation Network system (ORION) and its profile of hospital information, patient and emergency medical service characteristics, and in‐hospital outcomes among all patients transported to critical care centers and emergency hospitals in Osaka Prefecture, Japan.

Methods

The Osaka Prefecture Government has developed and introduced an information system for emergency patients (the ORION system) that uses a smartphone application (app) for hospital selection by on‐scene emergency medical service personnel and has been accumulating all ambulance records. Since January 2015, medical institutions have obtained information on the diagnosis and outcome of patients transported to medical institutions, and the ORION system merged these data with ambulance records including smartphone app data.

Results

From January 2015 to December 2016, 753,301 eligible patients were registered. The mean age was 58.7 years, and 51.5% of patients were male. After hospital arrival, 39.7% were hospitalized, 58.2% were discharged from hospital, 1.1% changed hospital, and 1.0% died. The most common diagnoses were injury, poisoning, and certain other consequences of external causes. Among the hospitalized patients, 29.2% were continuously hospitalized, 59.0% discharged, 5.2% changed hospital, and 5.8% were dead at 21 days after hospitalization. The most common confirmed diagnosis was diseases of the circulatory system.

Conclusion

Using the ORION system developed and operated by Osaka Prefecture since January 2015, we described the epidemiological data of all emergency patients transported to emergency hospitals. Analysis using the ORION database in the future could lead to improvements in the emergency transport system and patient outcomes.

Intelligent Surgeon's Arm Supporting System iArmS in Microscopic Neurosurgery Utilizing Robotic Technology

BACKGROUND

Based on our previous reports, stabilizing the surgeon's arm with an intraoperative armrest is linked to improved precision of microsurgical and endoscopic procedures. We developed the robotic intelligent surgeon's arm supporting system iArmS, which automatically follows the surgeon's arm and fixes it at an adequate position.

METHODS

iArmS has 3 states-free, hold, and wait-which can be carefully chosen automatically as follows: In free state, the armholder follows the surgeon's arm. In hold state, iArmS supports the surgeon's arm weight by fixing the armholder. In wait state, the surgeon can move his or her arm away from the armholder. Also, the surgeon can change the armrest position while looking through the microscope and can continue the microsurgical procedure while holding surgical instruments. From February 2015 to January 2017, iArmS was used in 108 microsurgeries at 3 of the authors' institutions by 14 board-certified neurosurgeons, including the authors. After using iArmS, to quantify neurosurgeons' satisfaction, a scaling evaluation guide based on visual analog scales was designed to be completed by contributing neurosurgeons, including authors.

RESULTS

iArmS decreased fatigue and reduced hand trembles experienced by surgeons. Continuous accurate motions of microinstruments were performed without any difficulties. There were no complications related to use of iArmS.

CONCLUSIONS

iArmS allows continuous precise manipulations that provide high-quality surgical results in neurosurgical techniques. Moreover, iArmS is a useful automatic tool for holding and following the surgeon's arm.

Giant thermal hysteresis in Verwey transition of single domain Fe3O4 nanoparticles

Most interesting phenomena of condensed matter physics originate from interactions among different degrees of freedom, making it a very intriguing yet challenging question how certain ground states emerge from only a limited number of atoms in assembly. This is especially the case for strongly correlated electron systems with overwhelming complexity. The Verwey transition of Fe₃O₄ is a classic example of this category, of which the origin is still elusive 80 years after the first report. Here we report, for the first time, that the Verwey transition of Fe₃O₄ nanoparticles exhibits size-dependent thermal hysteresis in magnetization, ⁵⁷Fe NMR, and XRD measurements. The hysteresis width passes a maximum of 11 K when the size is 120 nm while dropping to only 1 K for the bulk sample. This behavior is very similar to that of magnetic coercivity and the critical sizes of the hysteresis and the magnetic single domain are identical. We interpret it as a manifestation of charge ordering and spin ordering correlation in a single domain. This work paves a new way of undertaking researches in the vibrant field of strongly correlated electron physics combined with nanoscience.

Development concepts of a Smart Cyber Operating Theater (SCOT) using ORiN technology

Currently, networking has not progressed in the treatment room. Almost every medical device in the treatment room operates as a stand-alone device. In this project, we aim to develop a networked operating room called “Smart Cyber Operating Theater (SCOT)”. Medical devices are connected using Open Resource interface for the Network (ORiN) technology. In this paper, we describe the concept of the SCOT project. SCOT is integrated using the communication interface ORiN, which was originally developed for industry. One feature of ORiN is that the system can be constructed flexibly. ORiN creates abstracts of the same type of devices and increases the robustness of the system for device exchange. By using ORiN technology, we are developing new applications, such as decision-making navigation or a precision guided treatment system.

Probing optically silent superfluid stripes in cuprates

Unconventional superconductivity in the cuprates coexists with other types of electronic order. However, some of these orders are invisible to most experimental probes because of their symmetry. For example, the possible existence of superfluid stripes is not easily validated with linear optics, because the stripe alignment causes interlayer superconducting tunneling to vanish on average. Here we show that this frustration is removed in the nonlinear optical response. A giant terahertz third harmonic, characteristic of nonlinear Josephson tunneling, is observed in La_1.885Ba_0.115CuO₄ above the transition temperature T_c = 13 kelvin and up to the charge-ordering temperature T_co = 55 kelvin. We model these results by hypothesizing the presence of a pair density wave condensate, in which nonlinear mixing of optically silent tunneling modes drives large dipole-carrying supercurrents.

Strong localization of oxidized Co3+ state in cobalt-hexacyanoferrate

Secondary batteries are important energy storage devices for a mobile equipment, an electric car, and a large-scale energy storage. Nevertheless, variation of the local electronic state of the battery materials in the charge (or oxidization) process are still unclear. Here, we investigated the local electronic state of cobalt-hexacyanoferrate (Na _x Co[Fe(CN)₆]_0.9), by means of resonant inelastic X-ray scattering (RIXS) with high energy resolution (~100 meV). The L-edge RIXS is one of the most powerful spectroscopic technique with element- and valence-selectivity. We found that the local electronic state around Co²⁺ in the partially-charged Na_1.1Co²⁺_0.5Co³⁺_0.5[Fe²⁺(CN)₆]_0.9 film (x = 1.1) is the same as that of the discharged Na_1.6Co²⁺[Fe²⁺(CN)₆]_0.9 film (x = 1.6) within the energy resolution, indicating that the local electronic state around Co²⁺ is invariant against the partial oxidization. In addition, the local electronic state around the oxidized Co³⁺ is essentially the same as that of the fully-charged film Co³⁺[Fe²⁺(CN)₆]_0.3[Fe³⁺(CN)₆]_0.6 (x = 0.0) film. Such a strong localization of the oxidized Co³⁺ state is advantageous for the reversibility of the redox process, since the localization reduces extra reaction within the materials and resultant deterioration.

Coulomb Correlations Intertwined with Spin and Orbital Excitations in LaCoO_{3}

We carried out temperature-dependent (20-550 K) measurements of resonant inelastic x-ray scattering on LaCoO_{3} to investigate the evolution of its electronic structure across the spin-state crossover. In combination with charge-transfer multiplet calculations, we accurately quantified the renomalized crystal-field excitation energies and spin-state populations. We show that the screening of the effective on-site Coulomb interaction of 3d electrons is orbital selective and coupled to the spin-state crossover in LaCoO_{3}. The results establish that the gradual spin-state crossover is associated with a relative change of Coulomb energy versus bandwidth, leading to a Mott-type insulator-to-metal transition.

Sonodynamic Therapy Based on Combined Use of Low Dose Administration of Epirubicin-Incorporating Drug Delivery System and Focused Ultrasound

Sonodynamic therapy (SDT) is currently considered as one of the promising minimally invasive treatment options for solid cancers. SDT is based on the combined use of a sonosensitizer drug and high-intensity focused ultrasound (HIFU) to produce cytotoxic reactive oxygen species (ROS) in and around neoplastic cells. Anthracycline drugs, including epirubicin (EPI), have been well known as effective sonosensitizers after interaction with focused ultrasound. Recently a new anticancer drug delivery system (DDS), NC-6300, has been developed that comprises EPI through an acid-labile hydrazone bond. In previous in vivo studies, NC-6300 showed basic drug safety and an excellent concentration property of EPI, and recently has been tested in clinical trials. For realizing minimally invasive cancer treatment, the present study demonstrated the effectiveness and feasibility of DDS-based SDT, which combined a small dose of NC-6300 and low energy of HIFU in mouse models of colon cancer and pancreatic cancer.

Jahn-Teller distortion driven magnetic polarons in magnetite

The first known magnetic mineral, magnetite, has unusual properties, which have fascinated mankind for centuries; it undergoes the Verwey transition around 120 K with an abrupt change in structure and electrical conductivity. The mechanism of the Verwey transition, however, remains contentious. Here we use resonant inelastic X-ray scattering over a wide temperature range across the Verwey transition to identify and separate out the magnetic excitations derived from nominal Fe²⁺ and Fe³⁺ states. Comparison of the experimental results with crystal-field multiplet calculations shows that the spin–orbital dd excitons of the Fe²⁺ sites arise from a tetragonal Jahn-Teller active polaronic distortion of the Fe²⁺O₆ octahedra. These low-energy excitations, which get weakened for temperatures above 350 K but persist at least up to 550 K, are distinct from optical excitations and are best explained as magnetic polarons.

The Verwey transition of magnetite is complex due to the coexistence of strong correlations and electron-phonon coupling. Here, the authors use resonant inelastic X-ray scattering to show evidence for magnetic polarons in magnetite and provide insight into the nature of the transition.

Doping Dependence of Collective Spin and Orbital Excitations in the Spin-1 Quantum Antiferromagnet La_{2-x}Sr_{x}NiO_{4} Observed by X Rays

We report the first empirical demonstration that resonant inelastic x-ray scattering (RIXS) is sensitive to collective magnetic excitations in S=1 systems by probing the Ni L_{3} edge of La_{2-x}Sr_{x}NiO_{4} (x=0, 0.33, 0.45). The magnetic excitation peak is asymmetric, indicating the presence of single and multi-spin-flip excitations. As the hole doping level is increased, the zone boundary magnon energy is suppressed at a much larger rate than that in hole doped cuprates. Based on the analysis of the orbital and charge excitations observed by RIXS, we argue that this difference is related to the orbital character of the doped holes in these two families. This work establishes RIXS as a probe of fundamental magnetic interactions in nickelates opening the way towards studies of heterostructures and ultrafast pump-probe experiments.

Orbital Engineering in Nickelate Heterostructures Driven by Anisotropic Oxygen Hybridization rather than Orbital Energy Levels

Resonant inelastic x-ray scattering is used to investigate the electronic origin of orbital polarization in nickelate heterostructures taking LaTiO_{3}-LaNiO_{3}-3×(LaAlO_{3}), a system with exceptionally large polarization, as a model system. We find that heterostructuring generates only minor changes in the Ni 3d orbital energy levels, contradicting the often-invoked picture in which changes in orbital energy levels generate orbital polarization. Instead, O K-edge x-ray absorption spectroscopy demonstrates that orbital polarization is caused by an anisotropic reconstruction of the oxygen ligand hole states. This provides an explanation for the limited success of theoretical predictions based on tuning orbital energy levels and implies that future theories should focus on anisotropic hybridization as the most effective means to drive large changes in electronic structure and realize novel emergent phenomena.

Two cases of cryptogenic life-threatening hemoptysis - identification and management of bleeding point

Cases

Case 1: A 63‐year‐old woman was referred for coughing blood. Although cardiorespiratory dynamics were stabilized by artificial respiration under sedation, severely poor ventilation developed from asphyxia associated with massive respiratory tract hemorrhage. One‐lung ventilation was temporarily secured by endotracheal tube insertion into the left main bronchus just prior to cardiopulmonary arrest.

Case 2: A 72‐year‐old man was referred for massive hemoptysis after coughing, then intubated and placed on a respirator. During angiography, blood clots collected with bronchoscopy confirmed extravascular leakage into the right main bronchus.

Outcomes

Both showed no hemoptysis recurrence after bronchial artery embolization and were discharged. Case 1 required intensive treatment for 6 days, including artificial respiratory management.

Conclusion

Emergency one‐lung ventilation was required for asphyxia in Case 1, and we had difficulties with bleeding point identification and hemostatic therapy. From that experience, we noted hemoptysis during angiography using bronchoscopy in Case 2, enabling prompt bronchial artery embolization.

Raman and fluorescence characteristics of resonant inelastic X-ray scattering from doped superconducting cuprates

Measurements of spin excitations are essential for an understanding of spin-mediated pairing for superconductivity; and resonant inelastic X-ray scattering (RIXS) provides a considerable opportunity to probe high-energy spin excitations. However, whether RIXS correctly measures the collective spin excitations of doped superconducting cuprates remains under debate. Here we demonstrate distinct Raman- and fluorescence-like RIXS excitations of Bi_1.5Pb_0.6Sr_1.54CaCu₂O_8+δ. Combining photon-energy and momentum dependent RIXS measurements with theoretical calculations using exact diagonalization provides conclusive evidence that the Raman-like RIXS excitations correspond to collective spin excitations, which are magnons in the undoped Mott insulators and evolve into paramagnons in doped superconducting compounds. In contrast, the fluorescence-like shifts are due primarily to the continuum of particle-hole excitations in the charge channel. Our results show that under the proper experimental conditions RIXS indeed can be used to probe paramagnons in doped high-T_c cuprate superconductors.

An armrest is effective for reducing hand tremble in neurosurgeons

Experienced neurosurgeons reduce hand tremble by placing their hand beside the operative field when performing microneurosurgery conventionally. Another solution to reduce hand tremble is an armrest. However, the reduction of hand tremble by using an armrest or finger-placing technique has not been rigorously measured in microneurosurgery. This study was performed to provide a quantitative assessment of the efficacy of an armrest to reduce hand tremble in comparison with the finger-placing technique. Hand tremble was evaluated in 11 board-certified neurosurgeons in a simulated microneurosurgery. The loci of surgical forceps handled by neurosurgeons were measured by a three-dimensional optical coordinate measuring machine. A static task was performed under four conditions: with/without the finger-placing technique and/or an armrest. The radius of an imaginative sphere including 95% of each locus was calculated and reviewed according to the four conditions. Hand tremble was significantly larger when the finger-placing technique was not implemented compared to when the technique was used (P < 0.05). The armrest also reduced hand tremble (P < 0.05) similar to the finger-placing technique. Non-inferiority was retained between the finger-placing technique and the armrest. Concomitant use of the armrest and the finger-placing technique did not interfere with the efficacy of the technique to reduce neurosurgeon’s hand tremble. The finger-placing technique was confirmed to reduce hand tremble. Resting the neurosurgeon’s forearm on an armrest also reduced the hand tremble. An armrest is a device that reduces hand tremble in neurosurgeons like the finger-placing technique.

Robotic tensor device for optimal soft tissue balance in TKA

Soft tissue balance measurement is necessary for effective total knee arthroplasty (TKA). If optimal ligament balance is not achieved during surgery, it results in laxity of the knee or repeat surgery. In this paper, a newly developed robotic tensor system for measurement of soft tissue balance during TKA is described. The development concepts of the system were to measure collateral ligament balance (joint gap distance and varus angle) after cutting of the tibia and femur and to generate arbitrary lifting force to the knee joint during surgery. The system was created according to the development concepts. The prototype system has an active prismatic joint and a passive rotation joint to assess the joint gap and varus angle. The maximum lifting force is 250 N, the measurement range of the joint gap is 30 mm, and the varus angle is ± 15°. To confirm the force control ability, a basic experiment was performed. The input target force was 100, 150, 200, 250 N, and the output result showed an error within 3N. This experimental result shows that the newly developed system appears to have better accuracy than previous instrumental methods.

Gait Phase Detection Using Foot Acceleration for Estimating Ground Reaction Force in Long Distance Gait Rehabilitation

In gait rehabilitation, achieving a gait analysis method using a simple system during long-distance walking is important. This method is required to measure all gait parameters in a single measurement. In addition, it is required that the measurement system is not spatially constrained. Therefore, we have been developing a gait tracking system with acceleration sensors for long-distance gait rehabilitation. In this paper, we describe a gait phase detection method using foot acceleration data for estimating ground reaction force during long-distance gait rehabilitation. To develop this method, we focused on the jerk of each foot in vertical axis direction. Using two accelerometers mounted on the left and right feet, we carried out three experiments. First, we measured the jerk of each foot during a free gait to verify the relation with the walking speed. Second, we measured the jerk of each foot during walking faster than normal for each subject. We then compared these results with the results of first experiments. Finally, we measured the jerk of each foot during left-right asymmetrical walking. The results confirmed that gait phase could be detected using the jerk of each leg, calculated from acceleration data in vertical axis direction. In particular, the timing of Heel-contact / Toe-off could be obtained with an average error of 0.03 s. And as a preliminary study, we estimated the ground reaction force using the one of the results.

Origin of the large polarization in multiferroic YMnO3 thin films revealed by soft- and hard-X-ray diffraction

We investigated the magnetic structure of an orthorhombic YMnO(3) thin film by resonant soft x-ray and hard x-ray diffraction. We observed a temperature-dependent incommensurate magnetic reflection below 45 K and a commensurate lattice-distortion reflection below 35 K. These results demonstrate that the ground state is composed of coexisting E-type and cycloidal states. Their different ordering temperatures clarify the origin of the large polarization to be caused by the E-type antiferromagnetic states in the orthorhombic YMnO(3) thin film.

Wireless modification of the intraoperative examination monitor for awake surgery

The dedicated intraoperative examination monitor for awake surgery (IEMAS) was originally developed by us to facilitate the process of brain mapping during awake craniotomy and successfully used in 186 neurosurgical procedures. This information-sharing device provides the opportunity for all members of the surgical team to visualize a wide spectrum of the integrated intraoperative information related to the condition of the patient, nuances of the surgical procedure, and details of the cortical mapping, practically without interruption of the surgical manipulations. The wide set of both anatomical and functional parameters, such as view of the patient's mimic and face movements while answering the specific questions, type of the examination test, position of the surgical instruments, parameters of the bispectral index monitor, and general view of the surgical field through the operating microscope, is presented compactly in one screen with several displays. However, the initially designed IEMAS system was occasionally affected by interruption or detachment of the connecting cables, which sometimes interfered with its effective clinical use. Therefore, a new modification of the device was developed. The specific feature is installation of wireless information transmitting technology using audio-visual transmitters and receivers for transfer of images and verbal information. The modified IEMAS system is very convenient to use in the narrow space of the operating room.

Response Evaluation of Rollover Recognition in Myoelectric Controlled Orthosis Using Pneumatic Rubber Muscle for Cancer Bone Metastasis Patient

The myoelectric controlled rollover support orthosis we have been developing for use in bone cancer metastasis requires high accuracy and quick response in signal processing to recognize movement. We quantitatively evaluated the response performance of recognizing rollover using our original Micro Macro Neural Network (MMNN) algorithm. Required response time was calculated as 60 ms by measuring contraction time for the muscle used in the orthosis to support rollover. TheMMNN recognized rollover 65 ms before it started. Rollover was recognized 5 ms after a myoelectric signal was generated, so the MMNN response was sufficient for the muscle to finish contraction before rollover started.

EMX2 is epigenetically silenced and suppresses growth in human lung cancer

Lung cancer is a common cancer and the leading cause of cancer-related death worldwide. Aberrant activation of WNT signaling is implicated in lung carcinogenesis. EMX2, a human homologue of the Drosophila empty spiracles gene is a homeodomain-containing transcription factor. The function of EMX2 has been linked to the WNT signaling pathway during embryonic patterning in mice. However, little is known about the role of EMX2 in human tumorigenesis. In this study, we found that EMX2 was dramatically downregulated in lung cancer tissue samples and this downregulation was associated with methylation of the EMX2 promoter. Restoration of EMX2 expression in lung cancer cells lacking endogenous EMX2 expression suppressed cell proliferation and invasive phenotypes, inhibited canonical WNT signaling, and sensitized lung cancer cells to the treatment of the chemo cytotoxic drug cisplatin. On the other hand, knockdown of EMX2 expression in lung cancer cells expressing endogenous EMX2 promoted cell proliferation, invasive phenotypes and canonical WNT signaling. Taken together, our study suggests that EMX2 may have important roles as a novel suppressor in human lung cancer.

Telesurgery of Microscopic Micromanipulator System "NeuRobot" in Neurosurgery: Interhospital Preliminary Study

Object

Robotic surgery can be applied as a novel technology. Our master-slave microscopic-micromanipulator system (NeuRobot), which has a rigid endoscope and three robot-arms, has been developed to perform neurosurgical procedures, and employed successfully in some clinical cases. Although the master and slave parts of NeuRobot are directly connected by wire, it is possible to separate each part and to apply it to telesurgery with some modifications. To evaluate feasibility of NeuRobot in telesurgery, some basic experiments were performed.

Methods

The quality of telemedicine network system between Shinshu University and one of the affiliated hospitals, which was completely separated from other public network systems, was investigated. The communication delay was calculated from the transmitting and the receiving records in the computers set in each hospital. The relationship between the change in communication delay from the master part to the slave part of NeuRobot (0, 100, 300, 500 and 700 ms) respectively and feasibility of NeuRobot was investigated. The task performance time in each time changing group was compared. Feasibility of NeuRobot in telesurgical usage was evaluated. The master part and the slave part of NeuRobot placed in each hospital were connected through private network system. Interhospitally connected NeuRobot was compared with directly connected one in terms of task performance time.

Results

Less than 1 ms was required for corresponding the data in a steady transmitting state. Within 2 seconds after connection, relative time delay (maximum 40 ms) and packet loss were sometimes observed. The mean task performance time was significantly longer in over 500 ms delayed group compared with directly connected NeuRobot. There was no significant difference in the task performance time between directly connected NeuRobot and interhospitally connected NeuRobot.

Conclusion

Our results proved that telesurgical usage of NeuRobot was feasible. Telesurgical usage of telecontrolled manipulator system is recommended for application in a private network system in order to reduce technical and ethical problems. Some technical innovations will bring breakthrough to the telemedicine field.